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Legalease
Legalease, Lawyer
Category: Legal
Satisfied Customers: 16317
Experience:  15 years exp all aspects of general law
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I need to find an attorney that can help me write an appeal

Customer Question

I need to find an attorney that can help me write an appeal letter to my insurance company. I was supposed to have a lumber decompression surgery in January and I have spoken with a lawyer who can write the appeal, but it's going to cost $2000.00 for his assistance. I only make about $16000.00 a year. I am currently on long term disability due to the fact that I cannot sit in a seat for 8-10 hours a day without being in sever and extreme pain. I have all my doctors notes since this began in August 2014. I don't have that type of money and I am a single mother. I would appreciate any assistance.
Thank you,
***** ***** (###) ###-####(###) ###-####***@******.***
Submitted: 1 year ago.
Category: Legal
Expert:  Legalease replied 1 year ago.
Amber --
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Can you tell me why the insurance company has refused to permit you to have this surgery?
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Was this a work related accident or a car accident? How did this happen ?
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Can you scan into your computer the format that the health advocate sent to you ? While I cannot write the letter for you either (I am sorry but we have to refer you to local lawyers for that much in depth work) -- I can take a look at it to see if there is anything that I can do from here for you.
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Thank you
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MARY
Customer: replied 1 year ago.
The requested inpatient confinement is not covered because it is associated with a procedure which coverage has been denied. Medical Necessity Denial. This coverage denied was based on the terms of the member's benefit plan document. I have contacted Aetna to receive the benefit plan documents and have gotten no where. Those are the main highlights from the denial letter. My orthopedic surgeon referred me to a pain management doctor to have injections in my spine, and those didn't work, so he advised me to see my orthopedic surgeon. He suggested surgery and I was in agreement with him. I have doctors notes, mri results, disc o gram and multiple other tests and the insurance company paid for all those procedures leading up to the day of surgery.
Customer: replied 1 year ago.
I have all letters and notes and I can fax them or mail them to whoever can assist me.
Expert:  Legalease replied 1 year ago.
Hello there Amber -
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There must be a reason personal to you regarding why they have denied the surgery. The insurer may feel that your condition is not bad enough to warrant the surgery OR that you have not tried every possible thing before agreeing to the surgery. Whatever their reason for denial, if it is not crystal clear in their written letters to you, then you should call them up and speak with someone in the medical review department (there may even be a name of someone who is handling this at the insurer in the letters you have received and if so, you should ask to speak to that person) - and when you speak to that person, ask them to tell you specifically WHAT you need to do to get an approval for the surgery? Ask them (a) if a second opinion from another doctor would help and/or (b) if a letter from your own doctor stating exactly the reasons why the surgery is necessary would help. Once you have a clearer picture of the two or three things that you can do that will help your case, you should then make an appointment with the orthopedic doctor to discuss these matters with him. If the insurer will not give you any additional information, then you should look at this as a matter of getting them additional medical proof that the surgery is needed and you will benefit from it, as follows.....
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If you have not discussed their denial with your orthopedic surgeon then you should make an appointment immediately and bring in the denial letters and tell him exactly what the medical review person at the insurance company says that you need for an approval -- and then ask him if he will assist you with this matter. He can do two things to help you here -- (A) refer you to another doctor for a second opinion and if that second opinion comes back in your favor it can be referred to by the first doctor in his communications with your insurance company, and (B) write a letter to them stating why the procedure is medically necessary (at this point, he may not have given them a good enough explanation and if he gets an opinion from another doctor he may be more comfortable writing such a letter to the insurance company).
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Simply writing an appeal letter without knowing exactly why you were denied and without writing in that letter something that shoots holes at their denial will not get you approved for the surgery. They do not care if you ask them politely and say Please and if they can kick you to the curb and get away with it, they will. Once you gather some more ammunition against their denial using the suggestions above, that is when you should write the appeal letter and state that you have asked your surgeon to write a letter supporting the surgery and you have received a second opinion supporting the medical necessity of the surgery.
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For the most part, my guess is that they are claiming it is not medically necessary because many people simply choose to live in pain and not have the surgery (it is not a good choice -- I understand what you are going through because my husband has had one back surgery and needs another one and he has spent years in pain going to therapists, pain clinics, chiropractors -- you name it and he has tried it) and you must convince your doctor and the insurance company that the pain is so bad that you are literally ready to kill yourself over it and that the treatments that have been tried so far have not worked to alleviate your pain at all. That is the key -- your pain is so great that you MUST try the surgery to see if it can alleviate that pain and the doctors and the insurance company have no way to determine what your personal pain levels are because pain is something unique to every individual.
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If you then submit the opinions of two doctors and hopefully a written letter from your own doctor explaining to the insurance company that you need the surgery immediately if not sooner because of the constant gnawing pain that you have been stuck in since these injuries happened. If the insurance company still refuses the surgery then it is time to file a written complaint with your state division of insurance (every state has an agency that does nothing but license and regulate insurance companies -- including health insurance companies).
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Here is the exact website address where you can get instructions and forms to file a complaint with the Florida division of insurance:
http://www.floir.com/Office/SearchableTools.aspx
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I wish that I could give you information to send me the materials and assist you with this -- I actually do some of this work but we are not permitted to have contact with customers offline or perform these types of services through this website (we cannot get too close to what is called "attorney client representation because we are just a question and answer website). Anything that you can get scanned into your computer and then attach to a response box I CAN take a look at (within reason - a few pages) but I cannot get into a fax/mail correspondence for documents. The amount of money you were quoted to do this work for you was actually not unreasonable, but I do understand where you are coming from when you do not have an extra 20 bucks for something for your kids, let alone the amount of money that the attorneys quoted you to prepare the letter. I am also a single mother and contrary to what many people believe, we are not all wealthy lawyers running around country clubs. Yes, there are many lawyers who have done well, but most of us struggle along with the next person to make a living. I actually did not earn that much more than you did last year and I am still paying student loans (twenty years later) and relying on child support. If I handled this outside of Just Answer, I would still have to charge about $600 to do it because of the amount of time it would take for interaction with you, to review everything, give you direction on next steps, etc.
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So, what I am trying to do here is offer you an alternative. I am online at least some portion of everyday here at Just Answer and if you want me to assist you with this as you pull it together yourself, you can post additional questions and ask for me in the first line of the question "For Mary Legalease" and then the question will be directed to me and no one else will answer it. Yes, it will cost you some money, but I do believe that they have some trial plans where you can get unlimited questions for a certain period of time for one price -- if you check with customer service they will let you know exactly what is available (what is offered to the customers on any given day is not something that the experts are involved with because we are not permitted to be by the website - otherwise I would tell you what is available right now for customer incentives). If you do it this way, you can open a new question and let me know what the insurer and the doctor said to your requests and perhaps you can take your documents to staples or office max and ask THEM to scan them onto a disc, which you can then put into your own computer and attach the files from the disc to the Question box as we go along.
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Whatever you choose to do, it is your choice. I did tell you how I could approach this and help you for as minimal amount as possible after this first question and hopefully customer service can set you up with a good deal on an unlimited plan. In addition I did tell you what your next steps should be before writing the appeals letter and also gave you information regarding how to complain to the state insurance authorities. I do hope that you will keep this in mind when pressing a rating below and give me a positive rating for the assistance that I did give to you. If you leave this question without pressing a rating at all, I will receive nothing. If you press a poor or negative rating, I will receive nothing. If you press an OK or a GOOD or an Excellent rating below before leaving this question, I will be paid for my time assisting you (they will give me a portion of the deposit paid and it will not cost you any more money for this question and answer session). I truly would appreciate it if you would press a positive rating below so I will be paid for my time assisting you today. Even if you press a positive rating your question will NOT close and you can come back and post additional responses if you choose to do so and i will respond.
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Best of Luck with this -- whichever way you choose to take the matter.
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MARY
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